How to Build a Community Owned Health Plan

Ashtabula County, Ohio, a rural area east of Cleveland on Lake Erie, was a healthcare desert where employers and patients struggled with rising costs and accessing services. But starting around 2018, a coalition in the community pivoted away from the BUCAH insurance giants to a localized ecosystem. This led to huge savings, reinvesting the dividend and eliminating patient costs for services like MRIs, diabetic supplies and orthopedic care.

Bryce Heinbaugh, CEO of IEN Risk Management Consultants and the man behind this coalition, joined a recent episode of Moving to Value Unscripted to discuss the transformative model of community-owned health plans, and how his work in Ashtabula provides a strategic roadmap for communities around the country to reclaim control from national insurance giants.

Bryce shared some core strategies that helped him achieve success in Ashtabula:

1. Assemble a Healthcare Committee

The foundation of a community-owned health plan is governance that includes all stakeholders, not just the C-suite.

• Diverse Stakeholders: Include HR and CFOs as well as union leaders and care providers to ensure transparency and buy-in.

• Shared Fiduciary Duty: Educate the committee on their legal responsibilities under the Consolidated Appropriations Act (CAA), which requires employers to manage healthcare spend with the same rigor as any other business expense.

2. Create Transparent Financial Architecture

To bring down the rising per employee cost, the plan must move away from traditional extractive BUCAH models toward a system that aligns incentives with value for patients.

• Self-Funding & Independence: Utilize independent third-party administrators to gain autonomy over plan design.

• Eliminate Middlemen: Remove unnecessary money-handling middlemen to keep healthcare dollars within the local community.

• Lead with cash pay: Prioritize direct-pay opportunities enabled by hospital price transparency rules, which often result in fairer prices for services like MRIs.

3. Integrate Direct Primary Care

A community owned health plan functions best when built around a direct primary care model.

• The Patient-Centered Team: Recruit local, independent family physicians who operate on a membership basis rather than fee-for-service.

• Remove Barriers to Access: In Ashtabula, the plan offers direct primary care near the workplace with zero out-of-pocket costs for members, ensuring high utilization and early intervention.

4. Deploy Clinical Navigation

Concierge navigation is the engine that drives patients toward high-value care.

• Nurse Navigators: Hire specialized nurses to guide patients through complex medical decisions, helping them find providers with the highest quality and safety ratings.

• Incentivize Value: Waive deductibles and co-pays for patients who choose high-value, direct-contracted providers for surgeries, labs and imaging.

• Encourage Diagnosis Accuracy: Rural healthcare markets struggle to attract and retain high-quality physicians, specialists and sub specialists. Therefore, misdiagnosis can sometimes be prevalent, especially in cancer care and treatment. Nurse navigation makes second opinions for members entirely free, not only for oncology but also for surgical procedures and complex disease.

5. Formalize Direct Community Contracting

Instead of relying on broad national networks, build a local ecosystem of independent providers.

• Local Provider Network: Establish direct agreements with community pharmacists, physical therapists and mental health specialists.

• Strategic Recruitment: If a community is a healthcare desert for certain specialties, recruit from nearby regions to set up local clinical rotations.

Ultimately, the path to a community owned health plan relies on trusted relationships among local leaders. While this model may find easier footing in smaller communities where decision makers know one another better and can make decisions together faster, it can be scaled in larger metropolitan ecosystems. Bryce is at work bringing this model to communities in Maine, Rhode Island, Kansas, Colorado and elsewhere around the country.

Transitioning to community owned health plans is demanding work that requires navigating friction from entrenched interests and a departure from the status quo. However, with a clear vision and unwavering determination, any community can reclaim control and create a more transparent, sustainable healthcare system for its families.

Listen to our full conversation with Bryce to learn more.

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